Botulinum Toxin Management of Childhood Intermittent Exotropia

Abstract

Objective: Intermittent exotropia is a common form of childhood strabismus that has a late onset and presents a difficult and frustrating management dilemma. Surgical treatments have a high recurrence rate, and multiple surgeries often are required to achieve a desirable motor outcome. This study presents long-term observations on the use of botulinum toxin for the treatment of intermittent exotropia in children.Design: This study is a nonrandomized, case-controlled study of consecutive pediatric patients who had intermittent exotropia.Participants: Thirty-two neurologically normal children ranging from 3 to 144 months in age were diagnosed with intermittent exotropia with a minimum distance deviation of 15 prism diopters (PD).Intervention: Simultaneous bilateral injections of 2.5 units botulinum toxin type A were made into the lateral rectus muscles with the patient receiving nitrous oxide-ethrane inhalation anesthesia. Patients were observed for 12 to 44 months after the initial injection.Main Outcome Measures: A satisfactory outcome was considered to be stable binocular alignment of the eyes to an orthophoric range of ±10 PD.Results: Bilateral lateral rectus muscle injections of botulinum toxin were effective in reducing the mean preinjection deviation of −29 PD to an average exotropic angle of −6 PD. Stable orthophoria (± 10 PD) was achieved in 22 patients (69%). Overall, male patients required significantly fewer injections than did female patients. All patients between 24 and 56 months of age, irrespective of gender, required only a single bilateral injection to achieve a favorable motor outcome.Conclusions: Botulinum toxin is at least as effective as surgical outcomes reported previously for the treatment of intermittent exotropia in children. This treatment method is particularly effective in children between 2 and 4.5 years of age irrespective of the initial strabismic angle and is not associated with any secondary abnormalities.